Functional imaging in radiotherapy

FUNCTIONAL IMAGING IN RADIOTHERAPYVenue: Charles Darwin House, London

CPD: 6 CREDITS

10JULY 2015

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• Room1Primers for the non-specialistsSessionorganisedbyDrDavid

Wilson,ConsultantInterventional

MSKRadiologist,OxfordUniversity

HospitalsNHSTrust

• Room2Radiation protection — current issues in molecular imaging and radiotherapySessionorganisedbyMrAndy

Rogers,HeadofRadiationPhysics,

NottinghamUniversityHospitals

NHSTrust

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• Room1Clinical hybrid imaging inoncologySessionorganisedbyDrGopinath

Gnanasegaran,Consultant

PhysicianinNuclearMedicine,

StThomas’Hospital

• Room2Emergency radiology — advances in trauma imaging and Essentials for the radiology traineeSessionorganisedbyDrHardi

Madani,RadiologyRegistrar,Royal

FreeLondonHospitaland

DrAusamiAbbas,Cardiothoracic

RadiologyPostCCT

Day 2Day 1

BIR ANNUAL CONGRESS 20154–5 NOVEMBER

LONDON

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BIR Annual Congress 2015: 4–5 November, London

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Programme

09:00 Registration and refreshments

09:30 Welcome and introduction MrJamieDean,PhDStudent,TheInstituteofCancerResearch

09:45 An introduction to functional imaging modalities and what they can tell us DrSimonHughes,ConsultantinRadiologyandNuclearMedicine, NottinghamUniversityHospital

10:15 An introduction to radiotherapy MrChrisBowen,TherapyRadiographer,PlymouthHospitalsNHSTrust

10:45 Refreshments

11:15 Radiobiology for radiotherapy ProfessorKevinPrise,ProfessorofRadiationBiology, Queen’sUniversityBelfast

11:45 Functional MRI and its application to radiotherapy treatment planning DrRafalPanek,MRIPhysicist,RoyalMarsdenNHSFoundationTrustand InstituteofCancerResearch

12:15 MRI and quality assurance DrPeterWright,PrincipalMRPhysicist, SheffieldTeachingHospitalsNHSFoundationTrust

12:45 Lunch

13:45 PET-CT and its application to radiotherapy treatment planning DrRobinPrestwich,ConsultantOncologist,LeedsTeachingHospitals

14:15 PET-CT quality assurance MissLucyPike,ClinicalScientist,King’sCollegeLondonandGuy’sand StThomas’PETCentre

14:45 Radiobiological basis for dose painting DrChrisSouth,RadiotherapyPhysicist,RoyalSurreyCountyHospital

15:15 Refreshments

15:45 Radiotherapy trials utilising functional imaging DrLiamWelsh,ConsultantClinicalOncologist, TheRoyalMarsdenNHSFoundationTrust

16:15 The role of functional imaging and image registration for assessment of normal lung in thoracic radiotherapy DrRobIreland,LecturerinImageGuidedRadiotherapy, WesternParkHospitalandTheUniversityofSheffield

16:45 Functional imaging for response assessment DrMikePartridge,SeniorGroupLeaderforRadiotherapyPhysics, CRUK/MRCOxfordInstituteforRadiationOncology

17:15 Close of event

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BIR Annual Congress 2015: 4–5 November, London

Speaker profiles (where supplied)

Mr Chris BowenTherapy Radiographer, Plymouth Hospitals NHS Trust

ChristopherBowenisaTherapyRadiographercurrentlyworkingatthePlymouthOncologyCentreasaTreatmentDeliveryTeamLeadRadiographer.SincegraduatingfromtheSouthWalesSchoolofRadiographyin1994hespentmanyyearsasarotationalRadiographerbuthasspecialisedintreatmentdeliverysince2002.CurrentlyheundertakesspecialisedtreatmentssuchasStereotacticAblativeRadiotherapy(SABR)forlungcancers,CranialStereotactic,VolumetricModulatedArcTherapy(VMAT)andDeepInspirationBreathHold(DIBH).Additionallyhehasexperienceindifferentimagingmodalitiessuchasmegavoltage,kilovoltage,conebeamCTandimplantedmarkermatchingtechniques.

HealsoperformsandfacilitatestrainingforjuniorstaffinimagingandtreatmentdeliveryandistheLeadradiographerforthetruebeamlinearacceleratorandTreatmentFloorRadiationProtectionSupervisor.Hehasapassionforinnovationandimplementationofnewtechniquesanddeliveringhighqualityworldclassradiotherapywithinasmallbuthighlymotivatedandcommittedmultidisciplinaryteam.

Dr Rob IrelandLecturer in Image Guided Radiotherapy, Western Park Hospital and The University of Sheffield

RobIrelandisanacademicmedicalphysicistwithexpertiseinoncologyimageprocessingandclinicaltrials.RobhasbeenconductingradiotherapyimagingresearchanddevelopmentatWestonParkHospitalinSheffieldsince2001andiscurrentlyaLectureronImageGuidedRadiotherapyattheUniversityofSheffield.Robhaspublished20academicpapers,over90abstractsandhasreceivednumerousgrants,includingfundingfromCRUKandNIHR.ThemainthemesofRob’sresearchfocusonradiotherapyapplicationsofimageregistration,validationofventilationCT,andaninvestigationoftheroleofgasandprotonMRIinlungcancertreatmentplanningandpost-treatmentevaluation.

Dr Rafal PanekMRI Physicist, Royal Marsden NHS Foundation Trust and The Institute of Cancer Research

RafalPanekisanMRIPhysicistconductingresearchinthefieldoffunctionalMRIattheRoyalMarsdenNHSFoundationTrustandTheInstituteofCancerResearch.HiscurrentresearchfocusisanevaluationofparametersdefinedbydynamiccontrastenhancedMRI,bloodoxygenleveldependentMRIanddiffusionweightedMRIaspredictivebiomarkersofpooroutcomeinheadandneckpatientsandpreclinicalin vivostudies.DrPanekcollaborateswiththeMRIteamwithintheCancerResearchUK

CancerImagingCentreattheInstituteofCancerResearchandtheHeadandNeckclinicalteamattheRoyalMarsdenHospital,whichprovidesauniqueopportunitytoinvestigatetechniquesthatcanbeeffectivelytranslatedforthemanagementofpatients.

Dr Mike PartridgeSenior Group Leader for Radiotherapy Physics, CRUK/MRC Oxford Institute for Radiation Oncology

MikePartridgehasbeenworkinginmedicalimagingandradiotherapyresearchfornearly20years.HestudiednaturalsciencesatCambridgeUniversityandobtainedaPhDinimagingatCranfieldUniversitybeforeworkingasapostdoctoralscientistattheInstituteofCancerResearch,TheRoyalMarsdenHospitalandtheGermanCancerResearchCentreinHeidelberg.HemovedtoOxfordUniversityin2012tostartanewresearchgroupinradiotherapyphysics.Hiscurrentresearchfocusesonfunctionalimaginginradiotherapywithaparticularfocusonunderstandingthepotentialroleofhypoxiaimaging.Thisrangesfromcharacterisingheterogeneityatacellularlevelanddevelopingmathematicalmodelsthatlinkhypoxia,imagingandradiationresponsetoclinicalstudiesinvestigatingfunctionalimagingtopredictearlyresponsetotherapy.Whennotatworkheenjoysbirdwatchingandwalking.

Miss Lucy PikeClinical Scientist, King’s College London and Guy’s and St Thomas’ PET Centre

LucyPikeisaClinicalScientistattheKing’sCollegeLondonandGuy’sandStThomas’PETCentre,London.HercurrentroleinvolvesprovidingsupportforclinicalandresearchapplicationsofPET-CTincludingtheuseofnovelPETtracersandcompleximagingtechniques.InadditiontothisshemanagestheNationalCancerResearchInstitutePETCoreLab,whichprovidestechnicalsupportanddevelopsstandardsforPETimaginginmulticentreclinicaltrials.AspartoftherequirementforstandardisationinmulticentreclinicaltrialsinvolvingPET,shehasbeeninvolvedindevelopingaqualityassuranceprogramforinclusionofPETintoradiotherapytreatmentplanning.

Dr Robin PrestwichConsultant Oncologist, Leeds Teaching Hospitals

RobinPrestwichtrainedinmedicineatOxfordUniversitygraduatingin1998.HistraininginClinicalOncologywasbasedinLeedsandhegainedhisFRCRin2006.HecompletedaPhDasaCRUKClinicalTrainingFellowin2009exploringtheroleoftheimmuneresponseinoncolyticvirotherapy.FollowingcompletionofhistraininginClinicalOncologyin2011,hecompleteda1yearfellowshipintheDepartmentofNuclearMedicinewithhisresearchprimarilyrelatingtotheroleofPETforradiotherapyplanning.HehasbeenaConsultantinClinicalOncologysince2012andisthechiefinvestigatorofthreelocalstudiesexploringmultimodalityimagingforradiotherapyplanninginheadandneckcancerandlymphoma.

Professor Kevin PriseProfessor of Radiation Biology, Queen’s University Belfast

KevinPriseisProfessorofRadiationBiologyandDeputyDirectorattheCentreforCancerResearchandCellBiology,Queen’sUniversityBelfast,wherehehasbeensince2007.PriortothishewasHeadoftheCellandMolecularRadiationBiologyGroupattheGrayCancerInstituteinNorthwood,London.AbiochemistrygraduateofAberdeenUniversity,hehaswideranginginterestsinradiationbiologyincludinglowdose,radiationqualityandcellsignallingmechanisms.Hisrecentstudieshavebeenfocusedondevelopingnewbiological-basedmodelsforoptimisingadvancedradiotherapiessuchasintensitymodulatedradiotherapyandparticletherapies.Hehasover250publications.

Dr Chris SouthRadiotherapy Physicist, Royal Surrey County Hospital

ChrisSouthhasrecentlytakenuptheroleofheadofradiotherapydosimetryatStLuke’sCancerCentre,Guildford.FromAugust2012toJune2015hewasdeputyheadoftreatmentplanningatStLuke’s,priortowhichhespentoveradecadeasaclinicalradiotherapyphysicistattheRoyalMarsdenHospitalinSutton.In2005hebeganapart-timePhDattheInstituteofCancerResearchon“TheUseofFunctionalImagingtoDesignOptimalRadiotherapyDoseDistributions”,graduatingin2011.HehasbeenaregisteredClinicalScientistsince2005andhasanMScinMedicalPhysicsfromtheUniversityofSurrey(2001)andanMPhysfromOxfordUniversity(1998).Publicationsinclude“Atheoreticalframeworkforprescribingradiotherapydosedistributionsusingpatient-specificbiologicalinformation”(Southet al, Med. Phys.2008)and“Doseprescriptioncomplexityversustumourcontrolprobabilityinbiologicallyconformalradiotherapy”(Southet al, Med. Phys.2009).

Dr Liam WelshConsultant Clinical Oncologist, The Royal Marsden NHS Foundation Trust

LiamWelshreadphysicsattheUniversityofCambridgeandstayedontoresearchaPhDinstructuralbiophysicswithRichardPerhamandDonMarvinintheBiochemistryDepartment.AfteraperiodasaWellcomeTrustpost-docinRichardPerham’slab,LiamleftacademiatotraininmedicineatGuy’s,King’sandStThomas’MedicalSchool,graduatingwithhonoursin2004.AftergeneralmedicaltrainingatStBart’sandtheRoyalFreeHospital,LiammovedtotheRoyalMarsdenHospitaltotraininClinicalOncology.DuringhisSpRtrainingLiamspenttwoyearsasaclinicalresearchfellowwithintheHeadandNeckUnitattheRoyalMarsdenworkingonfunctionalMRIinheadandneckcancer.LiamwasappointedasaConsultantClinicalOncologistinNeuro-oncologyattheRoyalMarsdenin2015,andretainsaresearchinterestinfunctionalimaging.

Dr Peter WrightPrincipal MR Physicist, Sheffield Teaching Hospitals NHS Foundation Trust

PeterWrightisthePrincipalMRPhysicistatSheffieldTeachingHospitalsNHSFoundationTrustafterpreviouslybeingattheUniversityHospitalofNorthMidlandswherehesupportedthecommissioningofthreenewSiemensMRsystemsandsubsequentprotocolsetupandimagequalityimprovement.PriortotheUniversityHospitalsofNorthMidlands,Peterspent3yearsasthein-housephysicistatLeedsMusculoskeletalandBiomedicalResearchUnit(LMBRU),aNationalInstituteforHealthResearchfundedunitatLeedsNHSTrust.Thisroleincludedhisclinicalmedicalphysicstraining.PriortothisheobtainedhisPhDattheUniversityofNottinghaminfunctionalMRIandrelatedparametersusing7Tand3TMRIsystems.

Abstracts (where supplied)

An introduction to radiotherapy Mr Chris Bowen

Radiotherapyisahighlyspecialised,andeffectivetreatmentfortreatingcancer,howeveritcancauseseriousacuteandchronicsideeffectsincludinginducingsecondmalignancies.Owingtothisrisktheuseofionisingradiationisstringentlymonitoredtobeassafeaspossibleallowingdeliveryofoptimisedhighdosestotargetvolumeswhilesparingnormalhealthytissue.Inordertodothisradiotherapytreatmentsneedtobeextremelyaccuratetoreducerisktopatients.

Radiotherapyplanningreliesontheuseofdifferentimagingmodalitiestoprovideasaccurateapictureaspossibleofthetargetvolumerequiringtreatment.InturnRadiotherapytreatmenthastobedeliveredpreciselyandconsistently.Patientpositioningandmonitoringiskeytothereproducibilityoftreatments.

Manyfactorscaninfluencetheaccuracyoftreatmentdeliverybuttherearepracticalwaystominimisetheimpactofthesefactors.ThistalkaimstoprovideabasicintroductiontoRadiotherapyforaudiencememberswhoarenotconversantwiththedisciplineofRadiotherapy.

Educationalaims:• Todeliveranintroductiontoradiotherapyandpatientpathway• Presenttheadvantages,disadvantagesandbenefitsofradiotherapy• Outlinetheradiotherapypatientpathwayanddifferentdeliverymethodsof

radiotherapy• Definevolumesusedtodelineatetreatmenttargetareas• Highlightimportanceforconsistencyandaccuracyinradiotherapyplanningand

treatment• Provideinsightintohowdailypositionalaccuracyisassessedandmonitoredby

differentimagingmethods• Highlightsomeofthemajorissuesaffectingpatientposition• Discusspotentialinnovativedevelopmentsinradiotherapy

Learningobjectives:• Toprovidetheaudiencewithabriefandbasicintroductiontothenatureof

radiotherapytreatments• Demonstratethenecessityforaccurateandreproduciblepositioningfor

radiotherapypatients• Demonstratetheneedforgoodimaginginterpretationandprotocols

Radiobiology for radiotherapyProfessor Kevin Prise

Radiationbiologycontributestoradiotherapybyprovidingtheconceptualbasisforitsuseandprovidingrationaleforthedevelopmentofnewapproachesandtheschedulingchoicesthatneedtobemadeforitsdelivery.Underpinningthis

arethe“5Rs”ofradiationbiologywhichincludeintrinsicradiosensistivity,repair,repopulation,reassortmentandreoxygenation.Cancerisdefinedbyaseriesofhallmarksthatdifferentiatetumoursfromthecontrolledgrowthandmetabolismofnormaltissues.Manyofthesehallmarksleadtodifferencesintumoursthatimpactonradiobiologicalmechanismsandcanbeaccessedbyfunctionalimagingfortargetedradiotherapiesforbothclinicalandpreclinicalstudies.Thisoverviewlecturewillgiveanunderstandingofsomeoftherelevantconceptsfromradiobiology.

Educationalaims:• Reviewthebasicradiobiologicalprinciplesunderpinningradiotherapy• Reviewtheroleoffunctionalimagingfromaradiobiologicalperspective

Learningobjectives:• Understandthekeyhallmarksofcancer• Understandthe“5Rs”ofradiobiology

Furtherreading:• HanahanDandWeinbergR.A,(2011),Hallmarksofcancer:thenextgeneration.

Cell144,646-74• BossMK1,BristowR,DewhirstMW.(2014),Linkingthehistoryofradiation

biologytothehallmarksofcancer.RadiatRes.181,561-77.• BasicClinicalRadiobiology4thEdition,(EdsM.C.JoinerandA.VanderKogel)

ArnoldHodder2009

Functional MRI and its application to radiotherapy treatment planningDr Rafal Panek

Inadditiontohigh-resolutionmorphologicalimagesprovidingexcellentsofttissuecontrast,MRIcanalsobeusedtoobtaininformationonthefunctionalpropertiesoftissues.Thesetechniquesexploitpathophysiologicalchangesoccurringwithintumoursastheircontrastmechanism,suchasalteredperfusion,cellularityorbloodoxygenationlevel.Therefore,functionaltechniquesareincreasinglybeingusedfortumourdetection,monitoringoftreatmentresponse,anddetectionofrelapseddisease.FunctionalMRImethodssuchasdiffusionweightedimaging(DWI)andbloodoxygenleveldependentMRI(BOLD)arefunctionaltechniquesbasedontheendogenouscontrastinthetissue,whileotherssuchasdynamiccontrastenhanced(DCE)ordynamicsusceptibilitycontrast(DSC)arebasedonexogenousgadoliniumbasedcontrastagents.Intheradiotherapycontexttheultimategoaloffunctionalimagingistoidentifyradio-resistantdiseaseandthusprovideabiologicaltargetvolumefordoseboostingoralternativetreatment.Itcanalsobeusedtovisualizeorgansatriskandiswidelyusedtoidentifynervefibres,whichcanbeusefulforregionalsparing.GeometricaccuracyisthereforeessentialtoallowcorrectregistrationoffunctionalMRimageswithanatomicalMRIandCTdatasets.TheneedforpatientimagingintheradiotherapytreatmentpositionposesadditionalchallengesandrequiresdevelopmentofMRI-compatibleimmobilizationsetupsandRFcoilconfigurations.

ThispresentationwillcoveranintroductiontofunctionalMRImethods,examplesofmethodimplementationinthecontextofRTplanning(clinicaltrials)andchallengesinfunctionalMRI.

Learningobjectives:• TounderstandwhatfunctionalinformationcanbeobtainedusingMRI• TounderstandmainlimitationofmethodimplementationforRTplanning

Furtherreading:• PadhaniAR,LiuG,KohDM,ChenevertTL,ThoenyHC,TakaharaT,Dzik-

JuraszA,RossBDetal.Diffusion-WeightedMagneticResonanceImagingasaCancerBiomarker:ConsensusandRecommendations,Neoplasia2009;11(2):102-125.

• GalbánCJ,ChenevertTL,MeyerCR,TsienC,LawrenceTS,HamstraDA,JunckLetal.Theparametricresponsemapisanimagingbiomarkerforearlycancertreatmentoutcome.Naturemedicine,2009;15(5):pp.572-6.

• O’ConnorJPB,JacksonA,ParkerGJM,JaysonGC.DCE-MRIbiomarkersintheclinicalevaluationofantiangiogenicandvasculardisruptingagents.BritishJournalofCancer2007;96:189–195.

• NuytsS.Definingthetargetforradio-therapyofheadandneckcancer.CancerImaging2007;7:S50–S55.

• NewboldK,PartridgeM,CookG,SohaibSA,Charles-EdwardsE,Rhys-EvansP,etal.Advancedimagingappliedtoradiotherapyplanninginheadandneckcancer:aclinicalreview.BrJRadiol.2006Jul1;79(943):554–61.

• WelshL,PanekR,McQuaidD,DunlopA,SchmidtM,RiddellA,KohDMetal.Prospective,longitudinal,multi-modalfunctionalimagingforradicalchemo-IMRTtreatmentoflocallyadvancedheadandneckcancer:theINSIGHTstudy.RadiatOncol.2015May15;10(1):112.

• WangD,DoddrellDM.Geometricdistortioninstructuralmagneticresonanceimaging.CurrentMedicalImagingReviews2005;1:49-60.

• MetcalfeP,LineyGP,HollowayL,WalkerA,BartonM,DelaneyGP,VinodS,TomeW.ThepotentialforanenhancedroleforMRIinradiation-therapytreatmentplanning.TechnolCancerResTreat.2013Oct;12(5):429-46.

• vanderHeideUA,HouwelingAC,GroenendaalG,Beets-TanRGH,LambinP.FunctionalMRIforradiotherapydosepainting.Magneticresonanceimaging.ElsevierInc;2012Nov1;30(9):1216–23.

MRI and quality assuranceDr Peter Wright

TheMRIscannerisinitsveryanatureacomplexmachine,whichmeansthatwhengremlinsdogetintothesystemitcanbeveryhardtopinpointtheexactproblemquicklyandreturntheequipmenttoclinicaluse.Bysettingupandrunningarobustqualityassurancescheme,anyissueswiththeMRsystemwillbehighlightedatanearlystageandpotentiallyaidthemanufacturerengineersinidentifyingthespecificissueandallowaspeedyresolution.

ThistalkwillaimtohighlightwhatdeterminesimagequalityinMRandhowtheseparametersaremeasuredthroughqualityassuranceusingthemostcommonlyavailablephantoms.Finally,afewofthemostcommonartefactswillbepresented.Ofthoseartefactsproducedbyphysiologicaleffects,wewilldiscusshowtheseartefactscanbereduced.

Educationalaims:• ExaminethecomponentsofanMRsystem• Discusscontributorstoimagequality• ExamineparametersmeasuredaspartofaQAprocedureandavailable

phantoms• ReviewofartefactsseeninMRIandtheircause

PET-CT and its application to radiotherapy treatment planningDr Robin Prestwich

TherehasbeenanexplosionofinterestinthepotentialuseofPET-CTforradiotherapyplanning.Themajorityofworkhasfocussedon18F-fluoro-2deoxyD-glucose(FDG)althoughthereisinterestinimagingmultiplebiologicalprocesseswithnovelPETtracers.PET-CTmayhavearolein3keyareasofradiotherapyplanning:targetselection,tumourdelineation,treatmentindividualisationandadaptation.Intermsoftargetselection,PEThasacomplimentaryroletoanatomicalimagingforsometumourtypesalthoughforsometumoursitesnosuperiorityofPEThasbeendemonstrated;itisnecessarytobeawareofthepossibilityoffalsepositiveandnegativeresults.WithregardtotheuseofPETforcontouring,thequestionofwhetheritispossibletouseaqualitativediagnosticimagingmodalityforquantitativetumouredgedelineationremainscontroversial.MultiplemanualandautomatedalgorithmsforcontouringareasofPETavidityhavebeenproposed.Pathologicalvalidationisonlyavailableinalimitednumberofreportedseries.TheabilityoffunctionalimagingwithPETtoevaluatetumourheterogeneity/biologybothspatiallyandtemporallyhasledtointerestintheuseofPETimagingasanimagingbiomarkertoguideapproachestotreatmentindividualisation/adaptation.Significantchallengesremainpriortoadoptionintoclinicalpractice.

Educationalaims:• TolearnaboutthepotentialroleofPETinradiotherapyplanningfortarget

selection• TolearnaboutthepotentialroleofPETinradiotherapyplanningfortumour

contouring• TolearnaboutthepotentialroleofPETasanimagingbiomarkertoallowthe

individualisationoftreatment/on-treatmentadaptation

PET-CT quality assuranceMiss Lucy Pike

PETisincreasinglyusedfordiseasestaging,therapymonitoringandfollowupforarangeoftumourtypesinroutineclinicalmanagement.InmanytumourtypesPETcanprovidegreatersensitivityandspecificityfornodalstagingthanCTorMRandcandetectfunctionalchangesmuchearlierthananatomicalchanges.TheadditionalfunctionalinformationfromPETcancomplementtheanatomicaldataprovidedbyCTandthereismuchinterestinincorporatingthisintoradiotherapyplanningtohelpmoreaccuratelydefinetreatmentvolumesandpotentiallyreduceradiationdosestohealthytissue.ThereisanincreasingcasetosupporttheinclusionofFDG-PETinradiotherapyplanningforsometumourtypes,butinappropriateuseofPETtoreducetreatmentvolumescouldimpairratherthanimprovepatientoutcomes.ItisimportantthereforethatasolidevidencebaseisestablishedthroughclinicaltrialstodeterminehowPETimagingisbestutilisedinradiotherapyplanning.

EvaluationofvolumedelineationtechniquesincorporatingPETversusconventionalcontouringtechniquesinradiotherapyshouldbecarefullyplannedandexecutedthroughclinicaltrialsincorporatingrigorousandconsistentqualitycontrolandimagingprotocols.ThistalkaimstooutlinetheprocessesinvolvedinincorporatingPETintoradiotherapyplanninganddiscussessomeofthetechnicalchallengesthatmaybeencountered.InparticularthisdrawsonourownexperienceofdevelopingPET-CTprotocolsandthepatientpathwayforaphaseIFDG-guideddoseescalationstudy.

Educationalaims:• ToprovideanoverviewofthetechnicalrequirementsforincorporatingPET-CT

intoradiotherapyplanning• TodiscussthepracticalissuesofincorporatingPET-CTintoradiotherapy

planning

Learningobjectives:• Identifythestepsinvolvedinsettingupaqualityassuranceprogramforuseof

PETinradiotherapy• Identifythepotentialsourcesoferrorandhowtominimisethemthrough

rigorousQCtests

Referencesandcitations:• SomerEJ,PikeLC,MarsdenPK.RecommendationsfortheuseofPET

andPET-CTforradiotherapyplanninginresearchprojects.BritJRadiol.2012;85(1016):e544-8.

• ThomasCM,PikeLC,HartillCE,BakerS,WoodsE,ConveryDJ,etal.SpecificrecommendationsforaccurateanddirectuseofPET-CTinPETguidedradiotherapyforheadandnecksites.MedPhys.2014;41(4):041710.

• BoellaardR,Delgado-BoltonR,OyenWJ,GiammarileF,TatschK,EschnerW,etal.FDGPET/CT:EANMprocedureguidelinesfortumourimaging:version

2.0.EurJNuclMedMolImaging.2015;42(2):328-54.Furtherreading:• SattlerB,LeeJA,LonsdaleM,CocheE.PET/CT(andCT)instrumentation,

imagereconstructionanddatatransferforradiotherapyplanning.RadiotherOncol.2010;96(3):288-97.

• ThorwarthD,BeyerT,BoellaardR,DeRuysscherD,GrgicA,LeeJA,etal.IntegrationofFDG-PET/CTintoexternalbeamradiationtherapyplanningTechnicalaspectsandrecommendationsonmethodologicalapproaches.Nuklearmedizin-NuclearMedicine.2012;51(4):140-53

Radiobiological basis for dose paintingDr Chris South

Traditionallyakeyaiminradiotherapytreatmentplanninghasbeentodeliverauniformhighdosetoatumour.However,tumoursareknowntobebiologicallyheterogeneous,withvariationsinanumberoffactorsknowntoinfluenceradiationresponse.Modernmedicalimagingtechniquescanprovideinformationonthespatialdistributionofmanyofthesebiologicalparameters.Technologicaladvancesinradiotherapyallowcomplexdosedistributionstobecalculatedanddeliveredwithunprecedentedprecision.Itisthereforepossibletodesignnon-uniformdoseprescriptionsbasedonfunctionalimages,preferentiallytargetinghigherdosestotumourregionsathighestriskofrecurrence,aprocessknownasdosepainting.

Avarietyofmethodshavebeenproposedforlinkinglocaltargetdosetoimageintensity.Ingeneral,amodeldescribingtheradiobiologicalsignificanceoftheimagedataisusedtooptimiseanon-uniformtargetdosedistribution.Theefficacyofsuchmethodswilldependontheaccuracyoftheinterpretationandquantificationofimagesaswellasthecorrectnessoftheradiobiologicalmodel.

Dosepaintingistechnicallyfeasibleusingawiderangeofimagingmodalitiesandplanningtechniques.Uncertaintiesinimageinterpretationandradiobiologicalmodellingshouldbetakenintoaccountwhenpredictingtheefficacyofagivenmethod.

Educationalaims:• Tooutlinetheprinciplesofandrationalefordosepainting• Todescribetherelativeimportanceofvariousbiologicalandradiobiological

parameters• Tocompareandcontrastarangeofdifferentapproachestodosepainting

Learningobjectives:• Gainanappreciationoftherangeofimagingmodalitiesandmarkerswhich

maybeusedindosepainting• Gainanawarenessofthestrengthsandweaknessesofavarietyofmethods

forgeneratingtargetdosedistributionsfromfunctionalimages

The role of functional imaging and image registration for assessment of normal lung in thoracic radiotherapy Dr Rob Ireland

Educationalaims:• Toreviewfunctionalimagingofnormallungtissueinpatientswithlung

cancer• Tointroduceexamplesofimageregistrationapplicationsforlunganalysis

Learningobjectives:• TolearnaboutnovelapplicationsofSPECT,MRIandCTthatprovide

ventilationandperfusioninformationtoassistwiththeplanningandevaluationofradiotherapy

Aimsofimagingthe‘normal’lung:• Radiotherapyplanning:reducethedosetonormallungtissue• Evaluationoftreatment:assessradiationinduceddamagetonormallung

Methods:• SPECT:e.g.papersbyLawrenceMarks,MikePartridgeandKonstantin

Lavrenkov• HyperpolarisedgasMRI:PapersbyRobIrelandandJimWild• VentilationCT:PapersbyThomasGuerrero,RichardCastillo,Tokihiro

Yamamoto• VentilationMRI?SeveralpapersbyGrzegorzBauman

Results/findings:• Potentialreductionofdosetonormallungtissuedemonstratedinseveral

papers• Potentialidentificationofradiationinducedlungdamagealsodemonstrated

Keypoints/conclusions:• Reductionofdoseandidentificationofradiationdamageinlungcancer

patientshasbeeninvestigatedwithavarietyofimagingmodalities.Challengesstillexistbeforesuchtechniquescanbeusedroutinely

Referencesandcitations:• IrelandRH,etal.2007Feasibilityofimageregistrationandintensity-

modulatedradiotherapyplanningwithhyperpolarizedhelium-3magneticresonanceimagingfornon-small-celllungcancer.IntJRadiatOncolBiolPhys68273-81

• MarksLBetal.1997Physicalandbiologicalpredictorsofchangesinwhole-lungfunctionfollowingthoracicirradiation.IntJRadiationOncologyBiolPhys39563-570

• MunleyMT,MarksLBetal.1999Multimodalitynuclearmedicineimaginginthree-dimensionalradiationtreatmentplanningforlungcancer:challengesandprospects.LungCancer23105–114

• SimonBA2000Non-invasiveimagingofregionallungfunctionusingx-raycomputedtomography.JClinMonitComput200016433-42

• VinogradskiyYY,etal.2012Useofweekly4DCT-basedventilationmapstoquantifychangesinlungfunctionforpatientsundergoingradiationtherapyMedPhys39289-98

Furtherreading:• PartridgeM,etal.2010Imagingofnormallung,liverandparotidgland

functionforradiotherapyActaOncol49997-1011• SimonBA,etal.2012Whatcancomputedtomographyandmagnetic

resonanceimagingtellusaboutventilation?JApplPhysiol113647-57

Functional imaging for response assessment Dr Mike Partridge

Medicalimaginghasforalongtimeplayedanabsolutelycentralroleinradiotherapy,withx-RayCTbeingusedtoaccuratelyoptimisetreatmentsemployingpatient-specificanatomy.However,magneticresonanceimaging(MRI)andpositronemissiontomography(PET)enableustomapnotjustpatientanatomybutalsophysiologicalfunction,givingimportantinformationaboutthebiochemistryoftumoursinadditiontotheirphysicalcharacteristics(sizeandlocation).Forexample,weknowthatregionsoftumoursthathavelowoxygenlevels(hypoxic)offerresistancetobothradiotherapyandchemotherapy.

Byimaginghypoxictumourregionswecanmonitorresponsetotherapyand,forpatientswhodonotappeartoberespondingtoatreatment,eitherescalateradiationdoseoraddahypoxia-modifyingdrug(orboth).Dynamiccontrast-enhanced(DCE)anddiffusion-weighted(DW)MRIcanbeusedtomapbloodflowandperfusionand/ordiffusionpropertiesintissue,tellingusaboutoxygensupply.PETcanbeusedtomapglucosemetabolismusingfluorine-18labelledfluorodeoxyglusoce(18F-FDG)andhypoxiausingfluoromisonidazole(18F-FMISO).

Thereisgrowingevidencethatimagingchangesinearlyfunctionalresponsemayenablemoreaccuratepredictionofoutcomeinaspecificpatientthanjusttheirpre-treatmentimages.However,wedonotyetknowwhatthebestimagingmodalitytouseis,whattheoptimumtime-pointtoobserverresponseis,orwhetherimagingwithmorethanonemodalitywilladdadditionalinformation.

InthislecturewewillreviewsomeoftherecentlypublishedworkshowingtheuseofdwMRIandFMISOPETforearlyresponsepredictionanddiscusshowthisinformationmightbeusedinbiologically-adaptiveradiotherapyworkflows.

Educationalaims:• Togiveabriefoverviewofcurrentpublishedworkdemonstratingtheuseof

functionalimagingtoassessresponsetotreatment• Toillustratehowearlyresponseassessmentmightbeincorporatedinto

strategiesforbiologically-adaptivetreatment

Learningobjectives• Tolearnaboutcurrentpublishedworkdemonstratingtheuseoffunctional

imagingtoassessresponsetotreatment• Tolearnabouthowearlyresponseassessmentmightbeincorporatedinto

strategiesforbiologically-adaptivetreatment

Referencesandcitations:• Lambrecht,M.,etal.(2010).“Roleandvalueofdiffusion-weightedMRIin

theradiotherapeuticmanagementofheadandneckcancer.”ExpertRevAnticancerTher10(9):1451-1459.

• Hoeben,B.A.,etal.(2013).“18F-FLTPETduringradiotherapyorchemoradiotherapyinheadandnecksquamouscellcarcinomaisanearlypredictorofoutcome.”JNuclMed54(4):532-540.

• Zips,D.,etal.(2012).“Exploratoryprospectivetrialofhypoxia-specificPETimagingduringradiochemotherapyinpatientswithlocallyadvancedhead-and-neckcancer.”RadiotherOncol105(1):21-28.

• Tran,L.B.,etal.(2015).“Predictivevalueof(18)F-FAZAPETimagingforguidingtheassociationofradiotherapywithnimorazole:Apreclinicalstudy.”RadiotherOncol114(2):189-194.

Furtherreading:• Jaffray,D.A.(2012).“Image-guidedradiotherapy:fromcurrentconceptto

futureperspectives.”NatRevClinOncol9(12):688-699.

Platinum sponsors

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Wedevelopinnovativehealthcaresolutionsacrossthecontinuumofcare,inpartnershipwithcliniciansandourcustomerstoimprovepatientoutcomes,providebettervalue,andexpandaccesstocare.

Aspartofthismissionwearecommittedtofuellingarevolutioninimagingsolutions,designedtodelivergreatercollaborationandintegration,increasedpatientfocus,andimprovedeconomicvalue.Weprovideadvancedimagingtechnologiesyoucancountontomakeconfidentandinformedclinicaldecisions,whileprovidingmoreefficient,morepersonalisedcareforpatients.

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TheSiemensHealthcaresectorisoneoftheworld’slargestsupplierstothehealthcareindustryandatrendsetterinmedicalimaging,laboratorydiagnostics,medicalinformationtechnologyandhearingaids.Siemensoffersitscustomersproductsandsolutionsfortheentirerangeofpatientcarefromasinglesource–frompreventionandearlydetectiontodiagnosis,andontotreatmentandaftercare.Byoptimisingclinicalworkflowsforthemostcommondiseases,Siemensalsomakeshealthcarefaster,betterandmorecost-effective.

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